Pericarditis

Question 1

What is pericarditis? + pathophysiology

Answer 1

Pericarditis is the inflammation of the pericardium with/without effusion

The heart has an inner layer (visceral) (single cell layer)

And an outer layer (parietal) (mainly collagen and elastin)

Theres around 50ml of serous fluid

The great vessels lie in the pericardium, if the ascending aorta is ruptured, it will bleed into the pericardial space causing cardiac tampondade

Question 2

Causes of pericarditis

Answer 2

1. Viral (cocksakievirus) is the most common
2. Non-infectious like autoimmune (SLE), Trauma (MI), mets (lung, breast cancer)

Question 3

What is Dressler’s syndrome

Answer 3

Type of pericarditis, Autoimmune system response after damage to heart tissye/pricardium. Can happen after MI or trauma.

Question 4

Sx and signs of pericarditis

Answer 4

Sx
- chest pain, aggravated by inspiration, swallowing, coughing and lying flay. Relieved by sitting up and leaning forward. May have non-productive cough.
- distant heart sounds, obcured apex beats

Signs
- pericardial friction rub on auscultation (scratchy sound in midline)
- tachypnoea, tachycardia, fever
- dyspnoea, orthopnea (when cardiac tamponade develops)
- raised JVP
- hiccups (enlargement of heart touches phrenic nerve)

Question 5

What is cardiac tamponade?

Answer 5

cardiac tamponade is what happens when pericarditis causes the pressure on the heart to rise substantially.

Characterised by
- raised HR, low BP
- raised JVP
- Kussmaul’s sign: raised JVP during inspiration
- pulses paradoxus: SBP drops by >10mmhg on inspiration (due to septal bulge)
- Beck’s triad: falling BP, rising JVP, muffled heart sounds

Question 6

What are the Ix for pericarditis?

Answer 6

ECG (diagnostic):
- PR segment depression
- widespread ST elevation, concave-upwards, saddle-shaped ST [compared to STEMI, in which its raised only in affected areas]

CXR
- cardiomegaly if effusion
- pneumonia if bacterial infection

Echocardiogram
- if effusion or tamponade is suspected

Raised WCC, troponin

Question 7

Tx for pericarditis

Answer 7

• resitrict physical activity and bed rest
• NSAID (ibuprofen/aspirin) for 2 weeks
• Colchicine for repeat attacks

Surgial: pericardiocentesis to remove exudate (diagnostic and therapeutic)

Question 8

What is chronic pericarditis?

Answer 8

Usually preceded by acute pericarditis, chronic lasts >6mths. Certain causes of pericarditis like TB, bacterial infection –> pericardium becomes thick, fibrous and calcified. Pericardium becomes so inelastic that it affects diastolic and ventricular filling.

Condition is gradual, allowing for body to compensate (not acute like cardiac tamponade).

Distinguish from restrictive cardiomyopathy, similar in px but chronic pericarditis is treatable.

Question 9

Signs and Sx of chronic pericarditis

Answer 9

Similar to rHF
Sx:
- dyspnoea
- orthopnoea
- fatigue
- no chest pain (compared to acute pericarditis)

Signs
- elevated JVP
- hepatomegaly
- ascites
- peripheral oedema
- tachycardia

Question 10

Ix for chronic pericarditis

Answer 10

1st line: CXR
- small heart with/without pericardial calcification

ECG
- low voltage QRS with generalised T wave flattened/inversion

Echo
- thickened, calcified pericardium (helps distinguish from restrictive cardiomyopathy)

CT thorax to confirm

Question 11

Tx for chronic pericarditis

Answer 11

Surgial: pericardiectomy, risky but complete removal of pericardium